A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should nurse report to provider?

Correct Answer: A

Rationale: The correct answer is A: WBC 3,000/mm3. A low white blood cell count (WBC) can indicate bone marrow suppression from chemotherapy, leading to increased risk of infection. Reporting this value is crucial for timely intervention. B: Hemoglobin 14 g/dl is within the normal range and not typically a concern in this scenario. C: Platelet count of 250,000/mm3 is within the normal range and does not pose an immediate threat to the client. D: aPTT of 30 seconds is within the normal range and is not directly related to the client's current condition of breast cancer and chemotherapy.

Correct Answer: B

Rationale: The correct answer is B: Evaluation of the family's ability to effectively care for the older client. Rationale: 1. Evaluating the family's ability to care for the older client is crucial as it helps in assessing the overall support system available to the client. 2. Family members' involvement can provide insights into the client's daily care needs, potential challenges, and resources available for caregiving. 3. Understanding the family dynamics and capabilities helps the nurse in developing a comprehensive care plan that considers both the client's needs and the family's capacity to provide care. 4. This choice directly relates to the importance of involving family members in mental health assessment of older adults, highlighting the significance of assessing the caregiving abilities within the family unit. Summary: - A: While interviewing family members may provide information about social support resources, this is not the primary focus when evaluating the family's caregiving abilities. - C: Determining the extent of memory impairment is important but not the primary purpose of involving family

Correct Answer: C

Rationale: The correct answer is C. As individuals age, changes in liver functioning can lead to slower metabolism and clearance of medications from the body. This can result in medication levels accumulating in the system, potentially leading to toxicity. This explanation is important for the patient to understand the risks associated with their medications. Choice A is incorrect because the speed of stomach emptying does not necessarily impact medication effects. Choice B is incorrect as the entire GI system speeding up is not a typical age-related change and does not necessarily affect medication digestion. Choice D is incorrect as age-related circulation changes do not necessarily mean medications are delivered more quickly to specific body sites.

Correct Answer: A

Rationale: The correct answer is A because four-point restraints are used for clients who pose an imminent danger to themselves or others due to violent behavior, such as being hostile and threatening. Restraints should only be utilized as a last resort to ensure safety. Choices B, C, and D do not warrant the use of restraints as they do not involve immediate physical harm or danger. De-escalation techniques and alternative interventions should be attempted before resorting to restraint use.

Correct Answer: C

Rationale: The correct answer is C because during the first interview with a patient with a psychiatric disorder, it is crucial for the nurse to address relationship parameters to establish a therapeutic alliance, discuss the contract to clarify roles and expectations, ensure confidentiality to build trust, and explain termination to manage expectations. These aspects lay the foundation for a successful therapeutic relationship. A: Trust, congruence, attitudes, and boundaries - While trust and boundaries are important, they are part of relationship parameters addressed in choice C. Congruence and attitudes are more about the nurse's behavior than issues to address with the patient initially. B: Goals, resistance, unconscious motivations, and diversion - These are important aspects, but they are more relevant in later stages of therapy after a strong therapeutic alliance has been established. D: Transference, countertransference, intimacy, and developing resources - These are advanced concepts that may be addressed later in therapy as trust and rapport are established.

Correct Answer: C

Rationale: The most appropriate nursing diagnosis for a client with schizophrenia experiencing auditory hallucinations and illusions is "Disturbed sensory perception" (C). This diagnosis reflects the client's altered sensory experiences, such as hearing voices and experiencing illusions. It focuses on the client's perception of reality, which is impaired in this case. Choice A (Disturbed thought processes) is incorrect because it primarily focuses on cognitive processes rather than sensory experiences. Choice B (Risk for self-directed violence) is not the most appropriate because the client's symptoms do not directly indicate a risk of self-harm. Choice D (Ineffective coping) is also not as relevant in this case as the primary issue is related to sensory perception rather than coping mechanisms. Therefore, the correct diagnosis is "Disturbed sensory perception" as it addresses the client's altered sensory experiences.

Correct Answer: A

Rationale: The correct answer is A: Risk for Injury. Insomnia and sleep deprivation can lead to cognitive impairment and physical fatigue, increasing the risk of accidents and injuries. The nurse's priority is ensuring the client's safety. Option B, Ineffective Coping, focuses on emotional response rather than immediate safety concerns. Option C, Deficient Knowledge, does not directly address the client's current safety issue. Option D, Anxiety, is important but may not pose an immediate threat to safety compared to the risk of injury from sleep deprivation.

Correct Answer: A

Rationale: Step 1: Acknowledge individuality - By reacting to each child as unique individuals with their own talents and interests, parents can promote a sense of identity and reduce competition. Step 2: Encouraging positive interactions - Fostering cooperation rather than simply demanding it can help improve sibling relationships. Step 3: Address underlying issues - By focusing on individual needs and interests, parents can address root causes of rivalry rather than just surface behaviors. Step 4: Promoting healthy relationships - Encouraging children to appreciate each other's strengths and differences can lead to a more harmonious sibling dynamic. Summary: Choice A is correct as it addresses the core issues of sibling rivalry by promoting individuality and positive interactions. Choices B, C, and D are incorrect as they do not address the underlying causes of rivalry, promote unhealthy dynamics, or offer effective solutions.

Correct Answer: A

Rationale: The correct answer is A because effective nurse-patient communication is guided by principles of empathy, respect, and genuine concern. Patients value feeling understood and supported, which can foster trust and rapport. This approach helps alleviate the nurse's fear of saying the wrong thing by emphasizing the importance of good intentions and empathy. Choice B is incorrect because it assumes the patient is solely focused on talking and not listening, which can undermine effective communication. Choice C is incorrect because a patient's history does not guarantee immunity to harm from insensitive comments. Choice D is incorrect as it incorrectly generalizes about individuals with mental illness and forgiveness tolerance.